Received: 7 April 2020 Revised: 10 July 2020 Accepted: 13 July 2020

DOI: 10.1002/cre2.310

ORIGINAL ARTICLE

Composite restorations placed in non-carious cervical

lesions—Which cavity preparation is clinically reliable?

Anne-Katrin Lührs | Silke Jacker-Guhr | Hüsamettin Günay | Peggy Herrmann

Department of Conservative Dentistry,

Periodontology and Preventive Dentistry,
Hannover Medical School, Hannover, Germany
Correspondence
Anne-Katrin Lührs, Hannover Medical School,
Department of Conservative Dentistry,
Periodontology and Preventive Dentistry,
Hannover Medical School, Carl-Neuberg-
Straße 1, 30625 Hannover, Germany.
Email: luehrs.anne-katrin@mh-hannover.de
Funding information
Open access funding enabled and organized by
Projekt DEAL.
Abstract
The purpose of this in-vivo study was to evaluate the clinical performance of restora-
tions placed in non-carious cervical lesions (NCCLs), using different cavity prepara-
tion designs, after 7.7 years. A total of 85 NCCLs with coronal margins in enamel and
cervical margins in dentin were randomly assigned to the following treatment proto-
cols: dentin surface cleaning, dentin surface roughening with round bur plus flowable
composite, dentin surface roughening/cervical groove preparation with round bur,
dentin surface roughening/cervical groove preparation with round bur plus flowable
composite. After enamel beveling and selective enamel etching, the defects were
restored with composite. The restorations were assessed by two independent, cali-
brated and blinded investigators, using modified USPHS criteria. At 7 years (7.7
(± 0.35)), a total of 64 restorations (75.3%) were available for follow-up examination.
The total retention rate, irrespective of the test groups, was 82.8%. Restorations
placed without any preparation showed the highest loss rate (27.8%). Esthetic
appearance, marginal adaptation, anatomic form and marginal discoloration did not
differ significantly between the groups. Composites are long-term stable materials
for restoring NCCLs. Restorations placed without any dentin preparation (cavity
cleaning only) showed the highest loss rate.

KEYWORDS

cavity preparation design, class V-lesions, in-vivo study, NCCL, non-carious cervical lesions,
USPHS criteria

1 | I N T RO DU CT I O N one-third of them even show more than three lesions (Kolak

Non-carious cervical lesions (NCCLs) occur in all age groups (Borcic,
Anic, Urek, & Ferreri, 2004; Kolak et al., 2018; Yang et al., 2016), but
epidemiological studies have shown an increase of these defects at an
advanced age (Kolak et al., 2018; Yang et al., 2016). In the group of
over 55-year-olds, 94.7% of all patients examined have NCCLs, and
Anne-Katrin Lührs and Silke Jacker-Guhr contributed equally to this study.
et al., 2018).
The development of NCCLs is a multifactorial process. The most
common causes are erosion, abrasion and abfraction due to occlusal
interferences (Osborne-Smith, Burke, & Wilson, 1999). NCCLs are
often associated with hypersensitivities, esthetic impairments, and the
progression of cervical tooth structure loss. Especially when the cau-
ses of such lesions include erosion, a change in the toothbrushing
technique alone will usually not prevent the existing defect from pro-
gressing (Perez et al., 2012). Brushing frequency, contact pressure,

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© 2020 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

Clin Exp Dent Res. 2020;1–10. wileyonlinelibrary.com/journal/cre2 1

2 LÜHRS ET AL.

toothpaste abrasiveness and toothbrush hardness are cofactors for preparation) and the application of a flowable composite on the clini-
the development of NCCLs (Dickson, Vandewalle, Lien, Dixon, & cal long-term stability of cervical restorations.
Summitt, 2015; Sadaf & Ahmad, 2014; Wiegand & Schlueter, 2014). The null hypothesis which was set forth was that the different
NCCLs are frequently located on vestibular surfaces of premolars, pretreatment modes do not influence the retention rate and the clini-
followed by canines. Upper first premolars show the highest preva- cal behavior (based on modified USPHS criteria) of composite restora-
lence, while second molars and anterior teeth are least often affected tions placed in NCCLs.
(Aw, Lepe, Johnson, & Mancl, 2002; Borcic et al., 2004; Igarashi,
Yoshida, & Kanazawa, 2017; Kolak et al., 2018). When restorative
treatment of such defects is indicated, various factors may negatively 2 | M A T E R I A L S A N D M ET H O D S
influence the long-term stability of the adhesive restorations placed.
Cervical defects show structural differences from normal dentin, All procedures performed in this in-vivo study were in accordance
resulting from exposure to the oral environment (Palamara, Palamara, with the ethical standards of the institutional research committee
Messer, & Tyas, 2006; Walter et al., 2014). A heterogeneous, hyper- (No.: 4613) of the Hannover Medical School. All participants gave
mineralized surface is caused by prolonged exposure of dentin to their written informed consent before treatment.
saliva (El-din, Miller, & Griggs, 2004). It is characterized by high phos- This prospective randomized clinical study focused on follow-up
phate and low carbonate contents, a high proportion of crystalline examinations of composite restorations placed in NCCLs after
structures and partially denatured dentin (Karan, Yao, Xu, & 7.7 years of intraoral retention. Twenty-four patients with a total of
Wang, 2009). Due to dentin sclerosis, the bond strength of adhesive 85 NCCLs requiring treatment participated in the study. The clinical
composite restorations to dentin may be lower, which in turn might selection of the cervical defects was based on lesion depth. Following
lead to a higher restoration loss rate (Aw et al., 2002). the Tooth Wear Index by Smith and Knight (1984), cervical defects of
Furthermore, flexural forces occur in cervical cavities with incisal at least 1 mm in depth were included in the study. Table 1 summarizes
margins in enamel and cervical margins in dentin, as a result of the dif- all inclusion and exclusion criteria. The patient recruitment and all
ferent moduli of elasticity of these two structures (enamel: 84.1 GPa,
dentin: 16.6–18.6 GPa), so that the restorative material used has to
meet these special requirements (Craig & Peyton, 1958; Fennis
et al., 2005). TABLE 1 Inclusion and exclusion criteria
Basically, glass ionomer cements, compomers and composites in Inclusion criteria Exclusion criteria
various viscosities can be used to restore NCCLs (Cieplik et al., 2017).
Lesion depth ≥ 1 mm Lack of written informed consent
However, composites are the materials of choice, due to their esthetic to participate
and physical properties (Pecie, Krejci, Garcia-Godoy, & Cervical hypersensitivities Underage patients
Bortolotto, 2011; Perez et al., 2012). In addition to the
Restoration of tooth Carious cervical lesions
abovementioned factors, the cavity preparation design (Hakimeh, contour to prevent
Vaidyanathan, Houpt, Vaidyanathan, & von Hagen, 2000), adhesive periodontal damage
system and layering technique used influence the long-term stability Esthetic reasons Pregnant or nursing women
of such composite restorations (Borges, Borges, Xavier, Bottino, & Lesions with coronal Allergies to components of the
Platt, 2014; Boushell et al., 2016; Correia et al., 2018). Since the margins in enamel and materials used
development of NCCLs is usually a multifactorial process involving cervical margins in
dentin
different substrates, i.e., enamel and dentin, a combination of high-
Infectious diseases
and low-viscosity composites and the use of an incremental technique
Mucosal diseases with unclear
are considered to be the optimal treatment (Mullejans, Lang, Schuler,
diagnosis
Baldawi, & Raab, 2003; Perez, 2010). Cavity preparation design is
Inadequate oral hygiene
another influencing factor: U-shaped cavities show less microleakage
Bruxism
than V-shaped cavities in vitro (Hakimeh et al., 2000); this is in part
attributable to the fact that composite is more effectively packed High caries activity

when there are parallel cavity walls. Non-vital pulp

To date, only few in-vivo data on Class V restorations involving Severe periodontal diseases
composites of different viscosities or comparisons of different prepa- Severe dysgnathia/traumatic
ration designs have been published (Cieplik et al., 2017; Correia occlusion

et al., 2018; Karaman, Yazici, Ozgunaltay, & Dayangac, 2012; Li, No antagonist/adjacent tooth
present
Jepsen, Albers, & Eberhard, 2006; Mullejans et al., 2003; Szesz,
Parreiras, Martini, Reis, & Loguercio, 2017). Therefore, the aim of this Undergoing orthodontic
treatments
prospective randomized clinical study was to investigate the influence
Undergoing bleaching procedures
of dentin surface pretreatment (cleaning vs. roughening vs. groove
LÜHRS ET AL. 3

T A B L E 2 Overview over the four different treatment groups,

which were applied before the high viscous composite was placed

Group Code
1 CLEAN Dentin surface cleaning with fluoride-free
prophylaxis paste, application of adhesive
system after selective enamel etching
with phosphoric acid
2 PREP_FLOW Dentin surface roughening with round bur,
application of adhesive system after
selective enamel etching with phosphoric
acid, application of a thin layer flowable
composite to the cervical area
3 GROOVE Dentin surface roughening/cervical groove
preparation with round bur, application of
adhesive system after selective enamel
etching with phosphoric acid
4 GROOVE_ Dentin surface roughening/cervical groove
FLOW preparation with round bur, application of
adhesive system after selective enamel
etching with phosphoric acid, application
of a thin layer flowable composite to the
cervical groove

treatments took place between September 2007 and May 2008. The
last follow-up examination was carried out in June 2015.
At baseline, risk factors for extrinsic discolorations were docu-
mented, the teeth were tested for vitality, and the initial clinical situa-
tion was photographed. All patients received oral hygiene instructions
prior to restorative treatment.
The cavities included had coronal margins in enamel and cervical
margins in dentin and were randomly assigned (randomization list) to
one of the four test groups. The groups differed in the treatment pro-
tocols applied before composite application. The different groups are
displayed in Table 2.
Prior to restoration, all teeth were cleaned mechanically (Curette
Gracey Micro #7/8 Gr #9 MF, Everedge 2.0-SMS7/89E2, Hu-Friedy,
Tuttlingen, Germany) and with fluoride-free prophylaxis paste (HAWE
Cleanic, Kerr GmbH, Biberach, Germany) to remove organic and inor-
ganic deposits from the surfaces. After thorough rinsing of the cavities
with water for 30 s and subsequent drying, the tooth shades were
determined with the dedicated shade guide of the composite used
(Tetric EvoCeram, Ivoclar Vivadent, Schaan, Liechtenstein). In group
1, the dentin surfaces were not prepared; in groups 2 to 4, the
surface was roughened carefully with a round carbide bur
size 14/16, depending on the cavity size (H1SEM.204.014 VPE
5/ H1SEM.204.016 VPE 5, Komet Dental, Lemgo, Germany). For
the preparation of the fine cervical groove in groups 3 and 4 (Figure 1),
a size 010 round carbide bur (H1SEM.205.010 VPE 5, Komet Dental,
Lemgo, Germany) was used. The preparation was done with low
speed (2,000 rpm) without watercooling and with low pressure.
The coronal enamel margins of all cavities were bevelled approx.
1–1.5 mm, using a diamond finishing instrument (Flame No. 8862,
average grain size 30 μm, Komet Dental, Lemgo, Germany) with water
cooling (see Figure 1). A dry retraction cord without any hemostatic
F I G U R E 1 (a) Clinical situation before treatment, NCCLs located
at teeth 22 and 23, no gingival inflammation present. (b) Clinical
situation after surface roughening/groove preparation with retraction
cord in place. Cavity preparation design is illustrated at tooth 23.
Grey = small cervical groove (groups 3 and 4 only, depth max.
0.5 mm), dotted area: roughened dentin (groups 2,3 and 4; in group
1, this area was cleaned only), striped area: beveled enamel (all
groups)
agent (Ultrapak CleanCut Size 0, Ultradent Products, Köln, Germany)
was used to slightly displace the gingiva and make intrasulcular or
slightly subgingival preparation margins accessible. For an atraumatic
application of the retraction cord, a small packer (Fischer's Ultrapak
Packer, Small 45 Packer, Ultradent Products, Köln, Germany) was
used. Then, the enamel was selectively etched for 30 s with 36%
phosphoric acid gel (DeTrey Conditioner 36, Dentsply DeTrey, Kon-
stanz, Germany) and rinsed with water spray for 30 s. Dentin etching
with phosphoric acid is an optional working step when using Syntac
because of the self-etching primer, which contains maleic acid (see
Table 3). Therefore, dentin was pretreated with the self-etching
primer and not etched with phosphoric acid.
After rinsing the etchant off and drying the cavity surface, the
adhesive system (Syntac: Syntac Primer, Syntac Adhesive, Heliobond,
Ivoclar Vivadent, Schaan, Liechtenstein) was applied and light-cured
following the manufacturer's instructions (see Table 3). In Groups
2 and 4, a thin layer of flowable composite (max. layer thickness:
0.5 mm, Tetric EvoFlow, Ivoclar Vivadent, Schaan, Liechtenstein) was
applied to the cervical area/groove and light-cured for 20 s at
1,200 mW/cm2 with an LED curing light (Bluephase, Ivoclar Vivadent,
4 LÜHRS ET AL.

TABLE 3 Adhesive system and composite materials with Batch No., manufacturer's instructions and composition

Manufacturer's instructions/
Material Batch no. application Composition Manufacturer
HAWE Cleanic N.N. Application with prophylaxis cup to Silicates, humenctant (glycerine), Kerr GmbH,
without fluoride remove organic and inorganic binder, flavour Biberach,
deposits from the surfaces, Germany
thorough rinsing with water for
30 s, drying
DeTrey conditioner 36 1,006,002,311 Apply etching gel selectively on Phorphoric acid, water, silicon Dentsply DeTrey,
enamel, etching for 30 s, rinsing dioxide, water Konstanz,
for 30 s, drying with light air-flow. Germany
Syntac Primer K36299, L05849 Apply Primer to the cavity and Triethylene glycol dimethacrylate, Ivoclar Vivadent,
gently rub it in. Contact time at polyethylene glycol Schaan,
least 15 s. Disperse excess and dimethacrylate, maleic acid and Liechtenstein
thoroughly dry. acetone in an aqueous solution
Syntac Adhesive K36300, L02854 Apply Adhesive, leave it for 10 s, Polyethylene glycol dimethacrylate Ivoclar Vivadent,
and thoroughly dry the cavity with and glutaraldehyde in an aqueous Schaan,
an air syringe. solution Liechtenstein
Heliobond K37826, L05313 Apply Heliobond and blow it to a Bis-GMA, triethylene glycol Ivoclar Vivadent,
thin layer. Light-cure for 10 s at a dimethacrylate, stabilizers and Schaan,
minimum of 500 mW/cm2 catalysts Liechtenstein
Tetric EvoFlow J22244, K03621 Maximum layer thickness: 2 mm (or Bis-GMA, urethane dimethacrylate, Ivoclar Vivadent,
1.5 mm for Dentin shades). Light- decanediol dimethacrylate, barium Schaan,
cure for 20 s at ≥500 mW/cm2 or glass, ytterbium trifluoride, mixed Liechtenstein
for 10 s at ≥1,000 mW/cm2. Layer oxide, highly dispersed silicon
thickness was modified due to the dioxide, silanized, pre-polymer,
study protocol applied: max. additives, catalysts, stabilizers and
thickness 0.5 mm pigments
Tetric EvoCeram H13349, J27436, Maximum layer thickness: 2 mm (or Bis-GMA, urethane dimethacrylate, Ivoclar Vivadent,
K00012 1.5 mm for Dentin shades). Light- ethoxylated bisphenol-A Schaan,
cure for 20 s at ≥500 mW/cm2 or dimethacrylate, barium glass, Liechtenstein
for 10 s at ≥1,000 mW/cm2. ytterbium trifluoride, mixed oxide,
copolymer, additives, catalysts,
stabilizers and pigments, particle
size approx. 0.6 μm

Schaan, Liechtenstein). Then the defects were restored with a high-
viscosity composite which includes glass microfillers with a mean
particle size of 0.6 μm (Tetric EvoCeram, Ivoclar Vivadent) using an
incremental technique with a maximum increment thickness of 2 mm.
Each increment was light-cured for 20 s with the above-mentioned
curing light. Table 3 shows the materials used in the study.
The restorations were finished and polished with diamond
finishing burs (Flame No. 8862, average grain size 30 μm, Komet Den-
tal, Lemgo, Germany), polishing disks (Sof-Lex XT, 3 M Deutschland,
Neuss, Germany), the EVA System (KaVo, Biberach, Germany) with
oscillating files (Proxoshape PS2, Intensiv, Montagnola, Switzerland),
and silicone polishers (OptraPol, Ivoclar Vivadent, Schaan,
Liechtenstein).
After an average period of 7.7 years, the restorations were clini-
cally examined by two calibrated, independent and blinded investiga-
tors, using modified USPHS criteria based on Cvar and Ryge (Table 4)
(Cvar & Ryge, 2005). Also, bleeding on probing (BOP, periodontal
probe GY12, Deppeler SA, Rolle, Switzerland) at six sites (mv, v, dv,
mp/ml, p/l, dp/dl) around the respective tooth tested was evaluated
and documented.
The data was statistically analyzed using the chi-square test
(p < 0.05, SPSS 23.0, IBM Deutschland GmbH, Ehningen, Germany).
The inter-rater reliability was tested with Cohen's kappa coefficient.
3 | RE SU LT S
Sixty-four restorations (75.3%) out of 85 Class V restorations placed
in 24 patients (10 male, 14 female) were available for follow-up exam-
ination after an average period of 7.7 (± 0.35) years (shortest observa-
tion time: 6.8 years; longest observation time 8.2 years). The study
investigated 33 restorations in male patients aged 70.9 (± 8.8) years
and 31 in female patients aged 64.5 (± 11.9) years. Twenty-eight res-
torations (43.75%) were located in maxillary teeth and 36 (56.25%) in
mandibular teeth; Thirty restorations (46.88%) were placed in anterior
teeth, 33 (51.56%) in premolars, and one (1.56%) in a molar. The dis-
tribution of examined restorations during the follow-up was as fol-
lows: CLEAN: n = 12, PREP_FLOW: n = 12, GROOVE: n = 11 and
GROOVE_FLOW: n = 18. A total of nine out of the 64 restorations
available at the recall had been lost during the follow-up period. Due
 LÜHRS ET AL.

TABLE 4 Modified USPHS criteria based on Cvar and Ryge (2005)

Marginal
Esthetic appearance Marginal adaptation Anatomic form discoloration Axial contour Secondary caries Gingival response Hypersensitivity
A Good shade match No marginal gap Continuous transition No marginal Restoration matches No signs of caries No response No hypersensitivity
between visible or between discoloration tooth shape
restoration and detectable with an restoration and
adjacent tooth explorer tooth structure
structure
B Slight to moderate Marginal gap visible, Discontinuous Slight partial marginal Restoration slightly Secondary caries Gingival response Hypersensitivity
mismatch in shade but not extending transition, dentin or discoloration over- or under- without clinical attributable to
between to dentin or cavity cavity base not contoured inflammation hyperemia
restoration and base exposed
tooth structure, but
still esthetically
acceptable
C Severe discoloration Explorer insertable in Dentin or cavity base Severe circular Restoration Bleeding on probing Pulpitis/necrosis
gap, dentin or exposed marginal moderately over-
cavity base discoloration or under-contoured
exposed
D Restoration fractured, Insufficient Bleeding on probing
mobile, partially or restoration, and hyperplasia
totally missing severely over- or
under-contoured
5
6 LÜHRS ET AL.

F I G U R E 2 Comparison of the loss

rates (in %) of the four treatment groups
after 7.7 years, the loss rate of the group
CLEAN was significantly different from all
the other groups with surface preparation
(PREP_FLOW + GROOVE +
GROOVE_FLOW; p = 0.041)

TABLE 5 Examination results based on modified USPHS criteria

Group 1 CLEAN Group 2 PREP_FLOW Group 3 GROOVE Group 4 GROOVE_FLOW

USPHS ratings (n = 12) (n = 12) (n = 11) (n = 18)
Esthetic appearance
Alpha 91.7% 75% 100% 83.3%
Bravo 8.3% 25% 0% 16.7%
Marginal adaptation
Alpha 75% 75% 81.8% 77.8%
Bravo 25% 25% 18.2% 22.2%
Anatomic form
Alpha 100% 91.7% 90.9% 88.9%
Bravo 0% 8.3% 9.1% 11.1%
Marginal discoloration
Alpha 83.3% 58.3% 81.8% 66.7%
Bravo 16.7% 41.7% 18.2% 27.8%
Charlie 0% 0% 0% 5.6%

F I G U R E 3 (a) Cervical defects on teeth 32, 33 and 34, pre-operative situation, male patient aged 64. The defects on teeth 33 and 34 were
included into the study. (b) Restorations 33 and 34 during the first postoperative examination after one week. (c) Restoration during follow-up
after >7 years. The restoration on tooth 33 was rated “Bravo” for marginal adaptation and marginal discoloration, and “Alpha” for all the other
criteria. The restoration on tooth 34 was rated “Alpha” for all criteria

to restoration replacement of unknown origin and subsequent treat- 7.7 years, irrespective of the test groups, was 82.8%. Restorations
ment with a partial crown, two more restorations had to be excluded placed without any dentin preparation (CLEAN group) showed the
from evaluation. The total retention rate in the cohort investigated at highest loss rate (27.8%); this difference was statistically significant
LÜHRS ET AL.
when compared to the pooled groups which retrieved a pre-treatment
of the dentin surface (Group CLEAN vs. PREP_FLOW + GROOVE +
GROOVE_FLOW; p = 0.041). There was no statistical difference
between the treatment groups (Group PREP_FLOW vs. GROOVE
vs. GROOVE_FLOW, p = 0.328. Figure 2 shows the loss rates of the
treatment groups.
Based on modified USPHS criteria, the test groups did not differ
significantly in esthetic appearance, marginal adaptation, anatomic
form, and marginal discoloration (see Table 5).
All restorations in the group “GROOVE” examined at 7.7 years
properly matched the shade of the adjacent tooth structure. In con-
trast, one-quarter of the restorations in Group 2 (PREP_FLOW) had a
slight to moderate, but still esthetically acceptable, mismatch in shade.
Continuous transitions between restoration and tooth structure
resulting in a natural anatomic form were found in all restorations of
the “CLEAN” group. Approximately 10% of the restorations in the
other groups were over- or under-contoured. This difference was not
statistically significant (p = 0.716). The restorations in Group
2 (PREP_FLOW) were most frequently (41.7%) affected by partial
marginal discoloration. In Groups 1 and 3 (CLEAN and GROOVE), the
prevalence of partial marginal discoloration was lower (16.7% and
18.2%). One restoration (5.6%) in Group 4 (GROOVE_FLOW) was
rated Charlie for marginal discoloration. The differences between the
groups described were not statistically significant (p = 0.613). The rat-
ings of the restorations by the two investigators were in high agree-
ment (ĸ = 1).
Figure 3a-c shows a clinical case before treatment, one week
after the treatment was performed and after the follow-up period of
>7 years.
Comparisons between the treatment groups with regard to bleed-
ing on probing (BOP) did not show significant differences for any of
the six probing sites (p = 0.323). One case in the CLEAN group was
rated Bravo for gingival response (USPHS criteria: gingival response
without clinical inflammation, see Table 4).
None of the teeth available at the recall showed secondary caries,
and hypersensitivity was only reported in one case.
4 | DISCUSSION
This clinical long-term study investigated the performance of compos-
ite restorations placed in NCCLs depending on the cavity pre-treat-
ment. Restorations without any dentin preparation showed the
highest loss rate at 7.7 years. Therefore, the null hypothesis has to be
rejected in regard to the retention rate.
The challenges of clinical studies include increasing patient drop-
out rates and restoration losses (Peumans, De Munck, Van Landuyt, &
Van Meerbeek, 2015; van Dijken & Lindberg, 2015). The patient
cohort participating in this study was at an advanced age, which is
common in investigations dealing with restorations placed in NCCLs
(Kim, Cho, Lee, & Cho, 2017; van Dijken, 2010; van Dijken &
Pallesen, 2012). At baseline, 54% of the patients were over 60 years
of age. With a follow-up period of 7.7 years and 75.3% of the
7
restorations available at the recall, this investigation can be described
as a long-term study with a medium-range recall rate, based on the
classification by Peumans, De Munck, Mine, and Van
Meerbeek (2014). The total retention rate of 82.8% observed at
7.7 years is comparable to values found in the literature (Mahn,
Rousson, & Meta, 2015; van Dijken, 2010). In a meta-analysis
addressing the influence of bonding systems on the clinical long-term
stability of cervical restorations, retention rates were 82.6% at 5 years
and 67.7% at 8 years (Mahn et al., 2015).
The clinical success of cervical restorations depends mainly on
their adhesion to the tooth structure, due to the lack of mechanical
retention. One-step self-etch adhesives show an inferior “clinical
index” when compared to two-step self-etch or three-step etch &
rinse systems in this indication (Mahn et al., 2015). The “clinical index”
summarizes in-vivo success, taking into account the clinical results for
retention loss, marginal discoloration and marginal adaptation
(Heintze, Ruffieux, & Rousson, 2010). In our study, we placed adhe-
sively bonded composite restorations. This approach was selected on
the basis of favorable clinical data from other in-vivo studies
(Peumans et al., 2014; Peumans et al., 2015; van Dijken &
Lindberg, 2015). In our study we used the adhesive Syntac Classic in a
selective enamel etching mode (Ivoclar Vivadent, Schaan, Liechten-
stein) in combination with the system-inherent self-etching primer.
This three-step adhesive (Syntac Classic) applied with selective
enamel etching in NCCLs showed the lowest annual failure rate in a
follow-up period of 13 years and is considered to be a reliable unfilled
system (Korner, Sulejmani, Wiedemeier, Attin, & Tauböck, 2018; van
Dijken & Pallesen, 2008). Enamel etching is associated with improved
marginal adaptation, but not crucial to the retention rates of restora-
tions (Peumans, De Munck, Van Landuyt, Lambrechts, & Van
Meerbeek, 2007; Ritter, Heymann, Swift Jr, Sturdevant, & Wilder
Jr, 2008).
Dentin in cervical lesions shows highly sclerotic, hypermineralized
surface structures with obliterated dentinal tubules (Eliguzeloglu
Dalkilic & Omurlu, 2012; Sakoolnamarka, Burrow, Prawer, & Tyas, 2000;
Tay & Pashley, 2004). These structures cannot be completely
removed by etching and cause insufficient dentin hybridization when
left in place (Sakoolnamarka et al., 2000; Tay & Pashley, 2004). Clinical
investigations have shown additional roughening of the dentin surface
to be associated with significantly lower failure rates at times
(Eliguzeloglu Dalkilic & Omurlu, 2012; Mahn et al., 2015; van
Dijken, 2010). The reason is that mechanical preparation removes
sclerotic dentin, which prevents the formation of an adequate hybrid
layer (Mahn et al., 2015; Van Meerbeek, Braem, Lambrechts, &
Vanherle, 1994). This approach has not yet become sufficiently
established in clinical practice, although it may be essential to the
long-term survival of Class V restorations (Mahn et al., 2015). The
adhesive used in our study was originally designed for the “selective
etch-technique” and chosen because it was considered to be the
“golden standard” at the starting point of our investigation in 2007.
Nevertheless, both approaches, that is, self-etch and etch & rinse,
have a lower in-vitro bond strength to sclerotic dentin, as compared
to normal dentin (Karakaya et al., 2008; Kwong et al., 2002). Our
8 LÜHRS ET AL.
results support these in-vitro data, since our treatment group without
any preparation, that is, without removal of sclerotic superficial den-
tin, showed the highest loss rate at 7.7 years.
A systematic review and a meta-analysis addressed the question
as to whether flowables improve the marginal adaptation, marginal dis-
coloration and retention of NCCL restorations, when compared to con-
ventional composites (Szesz et al., 2017). Flowables showed better
marginal adaptation and similar marginal discoloration, although the
level of evidence was questionable. Composite viscosity did not seem
to influence retention rates at 3 years (Szesz et al., 2017). The use of a
flowable composite as a layer between dentin and a conventional com-
posite improved marginal adaptation in vitro (Li et al., 2006). Our study
does not support this result, as there were no significant differences in
marginal adaptation between the treatment groups (see Table 5). Gen-
erally, it should be noted that there are only limited long-term data on
adhesive restorations placed in non-carious Class V cavities. Most stud-
ies used follow-up periods of 3 years or less; only few investigators
selected periods of 5 years or more (Peumans, Wouters, De Munck,
Van Meerbeek, & Van Landuyt, 2018; van Dijken & Pallesen, 2012).
Besides, the study designs are heterogeneous. A distinction should be
made as to whether a flowable composite is only used to line the cervi-
cal cavity surface, as in our study, or to fill the entire cavity. When
using flowables cervically (dentin/cementum) and conventional com-
posites coronally (enamel), marginal adaptation and marginal discolor-
ation should be rated separately for the two different margins. This is a
limitation of our study; we only rated the restoration as a whole, with-
out differentiating between coronal and cervical margins.
In addition, we investigated whether the preparation of a mini-
mally invasive (i.e., 0.5 mm) groove influences Class V restorations.
The main reason for this cavity design was to reduce thin layers of
composite in epi-/subgingival areas adjacent to the cavity margin.
Without a precisely defined cavity margin, composite overhangs might
interfere with clinical parameters such as gingival inflammation, mar-
ginal discoloration etc. Our results showed that the preparation of a
groove in the cervical marginal area has no benefit on the clinical out-
come in Class V cavities. This might be explained by our clinical treat-
ment protocol: the retraction cord was placed in an atraumatic way
(see materials and methods), which ensured a good overview over the
treatment area. In groups were a flowable was used, the placing of
the first viscous composite increment was eased, as the oxygen inhibi-
tion layer seemed to be thinner when compared to Heliobond, and
the surface was therefore less “slippery.” Also, for finishing of the cer-
vical restoration margins, oscillating files (EVA System (KaVo,
Biberach, Germany) and Proxoshape PS2 (Intensiv, Montagnola, Swit-
zerland)) were used, which ensured the removal of overhangs. How-
ever, this cavity design was not addressed by any scientific
publications so far, which hampers a comparison with other clinical
studies. Nevertheless, the cervical groove and the use of a flowable
ease the manipulation of the composite, as a more sticky surface
exists and a clear margin is visible.
Secondary caries was not found in any of the restorations examined.
It was also a rare occurrence in other studies of restorations placed in
NCCL restorations (Peumans et al., 2015). However, participants in
clinical studies typically show good oral hygiene and a low caries risk.
Moreover, only non-carious cervical defects were restored (Nedeljkovic,
Teughels, De Munck, Van Meerbeek, & Van Landuyt, 2015). This finding
is in agreement with our results. The non-significant differences in gingi-
val response at the cervical restoration margin between the treatment
groups may be explained by the fact that the cavity margins were epi-
gingival or slightly supragingival at the recall (approx. 7.7 years postoper-
ative) as a result of age-related gingival recession.
5 | C O N C LU S I O N A N D CL I N I C A L
SI GNI FI CA NC E
Restorations placed without any dentin preparation showed the
highest loss rate at 7.7 years. Roughening of the dentin surface,
and/or the preparation of a fine groove led to a higher long-term sur-
vival of restorations placed in NCCLs and can be included into the
clinical treatment protocol of NCCLs.
AC KNOWLEDG EME NT S
The authors thank Dr. Bernhard Vaske for his valuable support regard-
ing the statistical analyses of the data. The authors declare that there
is no conflict of interests. Open access funding enabled and organized
by Projekt DEAL.
[Correction added on 22 September 2020, after first online publi-
cation: Projekt Deal funding statement has been added.]
CONFLIC T OF INT ER E ST
The authors do not have any financial interest in the companies
whose materials are included in this article. The authors declare that
they have nothing to disclose.
OR CID
Anne-Katrin Lührs https://orcid.org/0000-0001-5423-5583
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